What begins as a cautious questioning on known facts from Beals' CV blossoms into a deep conversation about the history of orthopedics in Oregon; changes in orthopedic technique, practice, and education; the challenges of modern medical economics; the advantages and disadvantages of sub-subspecialization; and finally, speculation about what the future may hold for orthopedics. Below are a few choice excerpts; the complete transcript is available upon request.
On socialized medicine in New Zealand:
BEALS: The longest time I spent away was in New Zealand where I practiced orthopedics. They arranged for me to be a New Zealand doctor for six months. And I have visited Australia several times, several places, and South Africa and so forth. But New Zealand was where I had the greatest experience. And it was interesting because New Zealand has had socialized medicine since the 1930s.On the training of specialists v. primary care doctors in Oregon:
One of the features of New Zealand medicine is that you don’t go to see a specialist as a first choice. You have to go to see your primary care doctor and then be referred to a specialist. And I was very interested to see what the effect of that was. I anticipated that I would see that patients’ diagnoses were missed because they were seeing primary care doctors and not specialists. I was anticipating that I might see where they weren’t as well cared for.
But the fact is, I didn’t find that. It turned out to be a very good system of medicine. And the key to it was the fact that they have extraordinarily well trained primary care doctors. Their primary care doctors have longer and better training than our primary care doctors here do. And I think that was the key as to how it works. So a place like New Zealand, and that would be true of Canada or Australia or England, they have roughly half as many orthopedists per capita as we do. And the reason for that is that an awful lot of the musculoskeletal complaints in those countries are pretty well taken care of by primary care doctors. And then when they’re referred to specialists, it’s primarily for a surgical procedure. Whereas in this country, orthopedists do a lot of non-surgical care. So it’s a contrast in style. And they both seem to work pretty well.
KRONENBERG: Can you talk a little bit about the, if you will, the limiting factors on increasing the size of a residency program in terms of the number of residents that are actually in a program? And I think that probably the same thing is true of other specialties. But speaking specifically of orthopedics, what are the determinates that either limit you or allow you to increase the size of a residency program these days?On E.G. "Frenchy" Chuinard:
BEALS: Well, first of all you have to have a certain number of patients available to be involved in a training program. That’s never a problem. Never a problem. We have to have a proper number of faculty to train them well, and that’s never a problem. What is, the biggest hazards are, determinates, first of all, your own institution: there’s a question of who’s going to pay for resident salaries. Residents make enough money that it’s a significant amount of money. Medical schools are given money for training, but it’s never enough. For instance, if we wanted to increase our residency number tomorrow, it would come out of the doctors’ income. Nobody is going to pay for that. So that’s a big drawback.
And then, another big drawback is the residency review committees of the national orthopedic groups. You have to get an okay. And most of those committees are dominated by people from the Midwest and the East. They’re a little reluctant to tell training programs that they can increase their size. So that’s always a bit of a problem. It takes quite a bit of work and a lot of data collection and so forth to convince the regulating bodies that you ought to have more residents. So I would say those are the two biggest handicaps to increasing the size of the residency program.
And then one other feature is, I think, that our medical school and many medical schools have for a long time taken the attitude that what they want to primarily produce are primary care doctors. They want internists, OB/GYNs, general practitioners, so forth, people in primary care. They don’t like to emphasize subspecialties. So I think that has an effect on something like orthopedics increasing size.
BEALS: Yes. I’d love to. Frenchy Chuinard was the first orthopedist to be fully trained in Portland. He had a year of training in the Shriners Hospital, a year of training at Emanuel Hospital, and a year of training at the County Hospital in Portland. And when he finished training, he was the seventh orthopedist in Oregon. That will give you a little perspective that things were, those were pretty early days.
Dr. Chuinard, as we called him, he was born in a farm up near Kelso. He went to University of Puget Sound. He was student body president there. He was always, always had something to say. And he had strong opinions. Sometimes he defied a lot of his colleagues. I always thought that his most important characteristic was his persistence. He never gave up. And I admire that. For example, when Dr. Dillehunt was the head of the Medical School, the library building was built, the outpatient building was built, the tuberculosis hospital was built, the nursing school was built. There were all kinds of things that were developed under Dr. Dillehunt. And yet, when it was all over and done with, there was nothing up there named after Dr. Dillehunt.
Dr. Chuinard was an extremely loyal person to Dr. Dillehunt. And he felt that was an affront to Dr. Dillehunt’s memory that they didn’t name one of the buildings up there after Dr. Dillehunt. So Dr. Chuinard made it a cause célèbre. And he pursued that year after year after year, and he finally got a building with Dr. Dillehunt’s name on it. It’s just a nice example of if it were not for his persistence, that never would have happened.
Dr. Chuinard was regarded as a very good teacher. He was chief of the Shriners Hospital for many years. And the residents all had a lot of contact with him. Dr. Chuinard had certain stories that he would tell over and over again to the point that the residents could all tell the stories. And it was a source of a little bit of amusement among the residents that they could replicate his stories.
Dr. Chuinard was a very good leader. He was president of the county medical society and I think the state medical society. And he became the vice president of the American Orthopedic Association which was nationally a rather big deal. His major interests in orthopedics were having to do with dislocated hips in babies. And he wrote a moderate amount about that. And he was a big promoter of certain treatment programs. He was a very important teacher to the residents. Influential within the residency. And was very active politically. And of course his wife was a state legislator. And he was sort of indirectly involved that way as well.
And then he had this interest in the Lewis and Clark expedition. He wrote a book on the medical aspects of it that’s quite a good book, called Only One Man Died. And it was a story of the medical experience of the trip of Lewis and Clark. I knew Bob, his son, very well, and Beverly, his daughter, I knew just minimally. But I knew that Bob and Beverly spent a lot of summers with their summer vacation taken to visiting all of these places that Lewis and Clark stayed. And they didn’t particularly think that was the greatest way to spend a summer. But Frenchy had strong feelings about visiting all these places and learning about it. I know that was a big part of their life.
So Frenchy had pretty strong feelings about it. And he developed great reverence, I think, for Lewis and Clark. And to this day I’ve found it slightly amusing that in his book, he never acknowledged that Lewis committed suicide. Because that would be not the right thing that he should have done. And I think Frenchy just couldn’t bring himself to accept that. And there was question of whether that’s really the way Lewis died. So I thought again that was an example of his stubbornness to accept the reality of what the evidence was.
But Frenchy was really a fine person. I liked him a lot. And he was very good for the training program.